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FINANCES &AMP; LEGALITIES

Death and taxes have always been twinned in cliché for their unavoidable awfulness. But death only happens to each of us once, not annually. Wouldn’t our annual encounter with the Internal Revenue Service be more aptly paired with the Medicare Part D open enrollment period, a yearly torture between mid-October and early December? Both take days out of our lives and leave us sitting in a heap of papers with a splitting headache and residual worry that we got something wrong and will wind up in jail or the poorhouse.

It’s my third year of eligibility for Part D, the Medicare option, added in 2006, that provides coverage for prescription drugs. When I turned 65, I had nothing but good things to say about Medicare Parts A and B, the 1964 hallmark legislation that covers hospital and outpatient medical care. That’s still mostly true, but for the growing numbers of doctors who have “opted out’’ of the government program because of inadequate reimbursement and onerous paper work. Part D, designed as a public/private hybrid, is another story. Forgive my cynicism, but any “benefit’’ that twins the insurance industry with Big Pharma can’t really have the public interest at heart.

My first experience choosing a drug plan was chronicled here, after a Fourth of July weekend that will live in memory as the worst I ever spent. I should have expected as much, since my colleague Gina Kolata, a whiz at math, wrote of her effort to choose a plan for her father, testing if the Centers for Medicare and Medicaid Services website was as simple as promised and found it an exasperating mess. Since my mathematical abilities are limited to counting on my fingers, and Gina had struggled, I was braced for trouble. But not the trouble I found myself in.

Year two I had an excuse not to try, even when the booklet of changes for the coming year arrived from my insurance carrier and everything was more expensive by many multiples. In the midst of selling one home and buying another, who could fault me for taking a slide? And how comforting to find out, and recount here, that a Kaiser Family Foundation study had found 87 percent of Part D policyholders between 2006 and 2010 made no change, even when they knew they were overpaying, because it was too hard. Kaiser went so far as to say that the Part D plans had observed and responded to this behavior, offering reasonable rates one year and over-the-moon rates the next in a classic bait-and-switch.

Now, in year three, I vowed I would behave responsibly and do what the experts advised: Review my current plan and its changes since 2014, then compare it to everything else available.

The biggest overall changes in Part D for 2015 are fewer plans to choose from. (Still, in 2015, there will be 1,001 Part D plans available nationwide, and an average of 30 in each region, for Part D’s 10 million customers.) Most of the plans are more expensive, and all have more drugs in the highest, more expensive tiers, with many requiring monthly pre-approval.

Experts also cautioned not to be seduced by plans with no deductibles versus those that expect the consumer to pay the first $320, since the medication you take will often push the total price higher than a $0 deductible plan.

Here’s when befuddlement set in. On the government website, medicare.gov, you can compare plans, but only three at a time. But I was interested in five. So I ended up going to the individual health insurers’ websites and punching into each the medications I take, the dosage and the frequency. There’s one plan with no deductible (I now pay $310) and a $30 (vs. $64) monthly premium. But all my drugs, now ranked at Tier One, the least expensive, would either bump up to Tier Four, the most costly, or require prior approval each and every month.

Sometimes figuring out each plan required a call to the health insurance company for clarification. In each case you have to to spell your name, give your date of birth, your phone number (home and cell), your mailing address and billing address, the last four digits of your social security number and your mother’s maiden name. Usually you have to say them more than once. In a half-dozen calls I spoke to agents named Bamer, Sergei, Miyosha, to name a few. All were very polite. Few understood the policies they were selling.

And some, relieving my tedium, went off script.

“You may want to contact your Social Security office.”

“I don’t have access to that book.’’

“That’s not something I’m familiar with. Please hold and I’ll get a supervisor.’’

The temptation to hang up was trumped by knowing I’d only have to start over.

At the end of the process, after adding up all the numbers and seeing which plan was most economical for me, I had a new plan. It had taken me two days, maybe 10 hours. I wish I had started earlier but, like taxes, we procrastinate. And those wishing to change their plan have only until Dec. 7, a Sunday, to make a change.

My new plan came with a 16-digit customer I.D. number. There was also a customer service phone number, available 8 a.m. to 8 p.m. seven days a week. Somehow, I’d wind up automatically disenrolled from my current plan and one refill on each prescription would be transferred from my existing pharmacy chain to the new one, which is right across the street. If I did the math right, this would cost me about $800 a year. That seemed reasonable, assuming unanticipated medications didn’t get added to the list.

I’d made a decision. In a year I’d know if it was a good one. Meantime, my cholesterol medication has been discontinued. It was one where the new plan saved me a dollar a month. And I might as well pay for a Tier Four shingles vaccine now. If I dawdle until after the first of the year, it will cost $250 because the deductible won’t be met. Now I can get one for $95.

The pharmacy I now must use advertises on television as being “at the corner of healthy and happy.’’ Only time will tell.

The facts: In September 2008, Carolyn Gregory, 54, was washing dishes in the home of Lorraine Cott, an 88-year-old woman with advanced Alzheimer’s. Without warning, Ms. Cott came up behind Ms. Gregory, knocked into her and began reaching toward the sink. As the caregiver struggled to restrain the older woman, a large knife Ms. Gregory was washing fell and sliced into her left hand. Ms. Gregory subsequently lost sensation in her thumb and two fingers and experienced considerable pain.

Since Ms. Gregory was employed by a home health agency, she was entitled to redress for the injury under the agency’s workers’ compensation policy. The question at issue was whether she could sue Mr. and Mrs. Cott (both died last year) for negligence as well.

In a 5-to-2 ruling, the California Supreme Court said the caregiver could not, citing a legal doctrine known as the “primary assumption of risk.” That principle holds that workers who perform jobs they know to be dangerous — firefighters and police officers are primary examples — cannot seek recompense from clients when bad things happen, as might be expected, on the job.

“Those hired to manage a hazardous condition may not sue their clients for injuries caused by the very risks they were retained to confront,” Justice Carol A. Corrigan wrote in the majority opinion. This applied to Ms. Gregory, the court said, because she knew Ms. Cott could be violent and dealing with the elderly woman’s difficult behavior was one of her primary responsibilities.

This “assumption of risk” legal principle had previously been established for institutions that serve Alzheimer’s patients; the new ruling extends it to home health aides in California. The justices asserted that there was a public policy interest in treating people with disabilities in the communities where they live.

“If liability were imposed for caregiver injuries in private homes, but not in hospitals or nursing homes, the incentive for families to institutionalize Alzheimer’s sufferers would increase,” Justice Corrigan wrote.

The California Supreme Court noted that its reasoning applies only to “professional home health care workers who are trained and employed by an agency.” That leaves open the question of how the court might handle injured home care workers hired through registries (independent contractors, not registry employees) or employed directly by families.

Recognizing the complexity of issues at stake in this case, the court also recommended that the California Legislature examine training requirements and “enhanced insurance benefits” for Alzheimer’s caregivers.

“While we’re disappointed with the court’s decision, we’re gratified that it recognized that adequate training and protection for home care workers are important considerations,” said Matthew Stark Blumin, associate general counsel of the American Federation of State, County and Municipal Employees, which filed an amicus brief supporting Ms. Gregory.

“Home care agencies need to ensure that caregivers for dementia patients understand what this kind of work is about and the potential for risk and harm,” said William A. Dombi, vice president for law at the National Association for Home Care & Hospice. “Workers shouldn’t be able to say they didn’t know what they were getting into. And, in the end, that’s good for consumers.”

Earlier this month Representative Nita M. Lowey, Democrat of New York, introduced what she’s calling the Social Security Caregiver Credit Act, intended to increase retirement income for middle-class citizens who must reduce their work hours or leave the work force because of caregiving duties.

It’s hard to feel optimistic about its passage in this political environment. I’m braced, even here, for a chorus of “How can we possibly afford that?” But you can’t really argue with the problem it tries to address.

The toll that family caregiving can take isn’t only emotional and physical; it’s also financial, but not always in obvious ways.

The groceries you pick up on the way to see your mother, the utility bills you quietly pay for your aunt — you’re aware of those. If you cut back your hours, turn down promotions or leave your job, as some caregivers feel forced to, you’re keenly conscious of your lost income.

But I wonder how many people consider the ways that their own retirements, years down the road, may suffer. The pressures of caring for a disabled or dependent family member can reduce Social Security income for the rest of the caregiver’s life.

In January, I reported the sad tale of his elderly parents, whose confusion allowed their long-term care insurance to lapse. Though Anne and David Pirron had faithfully paid John Hancock about $50,000 in premiums over 11 years, which would have entitled them to about $600,000 in benefits through their joint policy, the elder Mr. Pirron had gone to his bank and mistakenly stopped the auto-payment system his son had set up.

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Anne and David Pirron.Credit Michael Pirron

When John Hancock sent notices that their coverage was about to end because they’d stopped making payments, the Pirrons didn’t know what to do with them and stashed them in a drawer. Their son found the letters months later, when his mother needed more care and he wanted to tap their benefits.

An only child, Michael Pirron was their designated third party, meaning the insurer was supposed to send notices of any change to him, as well as to his parents. Hancock said it sent such a notice; Mr. Pirron said he never got one. He had no legal recourse under Virginia insurance regulations except a lawsuit that would have cost far too much. So the older Pirrons had to sell their condo and downsize into a modest apartment in Richmond, where Mrs. Pirron now receives care through a Medicaid-funded PACE — Program of All-Inclusive Care for the Elderly.

To try to prevent this from happening to other families — and it probably does, because the inability to manage finances effectively is one of the early signs of looming dementia — Michael Pirron and the state AARP lobbied the Virginia Legislature to require insurers to send third-party notifications by certified mail. The bill died in committee last winter, but this month the state Bureau of Insurance took action and went one better.

When an elderly parent dies, his children are supposed to be able to settle a reverse mortgage for a percentage of the home’s value. Instead, some lenders are moving to foreclose as quickly as possible, The Times reported on Thursday. Read the full story.

Dr. Richter, 83, has served on corporate boards. He directed the Stanford Linear Accelerator Center for 15 years, among his other faculty and administrative positions at the university. And his honors include the Nobel Prize in physics.

The five other named plaintiffs in the proposed suit have impressive resumes, too, with an abundance of advanced degrees. Yet when they grasped that Vi’s management had not stashed their sizable entrance fees in a reserve account, “it astounded me and a lot of the residents,” Dr. Richter said.

C.C.R.C.s are state regulated, and “there is no consistency from state to state as to what residents’ rights are,” said Katherine Pearson, a Penn State law professor and authority on this type of senior housing. Though such communities come in many configurations — some operate more like rentals, without big upfront fees — buying into a place like the Vi can take most of a resident’s life savings.

Yet most state regulations, if they exist at all, emphasize disclosure more than consumer protection. “You can have a financial disclosure law that puts 99 percent of the burden on the resident to understand its significance,” Ms. Pearson said. New York and New Jersey have strong C.C.R.C. regulations, she said; Virginia’s are weak, and California’s have serious gaps. Most don’t require reserve funds for the eventual refunds of entrance fees.

Yet after decades of adequately handling their own money, older people understandably resist ceding control. Can’t we leave them some autonomy — the ability to support a favorite charity or carry some walking-around money or buy a new purse — without the risk that they may impoverish themselves?

A thought: The use of prepaid debit cards as a substitute for credit cards and checking accounts has grown enormously in the past few years. A Pew Charitable Trusts survey earlier this month reported that 5 percent of American adults use them at least monthly and that the amount of money loaded onto them — $65 billion in 2012 — has more than doubled over three years.

Few card users were over age 65, Pew found — just 5 percent. But maybe more of them could or should be.

Michael Pirron runs a technology consulting company in Richmond, Va. For some time, he fretted about his parents, about what would happen if, like most older Americans, they needed expensive care as the years passed. They were still young-ish and comparatively healthy, but his father’s mother had lived to be 105.

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Anne and David Pirron.Credit Michael Pirron

So in February 2001, when David Pirron was 67 and his wife Anne was 59, Michael helped them buy joint long-term care insurance policies, with benefits that rose annually, from John Hancock. When the time came, it would provide up to $600,000 to pay for home care, adult day care, assisted living or a nursing home.

“I’m an only child,” Mr. Pirron told me. “I’m not independently wealthy. This was the way I could be sure they had care when they needed it.”

The older Pirrons gave him their power of attorney, as experts perennially urge. They signed the form making their son the third party designee that John Hancock would notify of policy changes or anything that could cause the policies to lapse. But, to ensure that they remained in force, Michael Pirron made arrangements with his parents’ bank. “I made sure my dad had auto-pay so that the premiums got paid every month,” he said.

In the years that followed, the couple downsized from a house in Washington to a condo in Fredericksburg, Va., an hour away from Michael. They faithfully paid about $50,000 in long-term care premiums over a decade, Michael estimates, and never made a claim.

But the crisis arrived, as it often does. By 2012, Mrs. Pirron was falling and had developed psychiatric symptoms, and her husband had become too confused and forgetful to remain her caregiver. Michael Pirron called John Hancock to ask about the care options covered by his parents’ insurance.

“Their answer was, essentially, ‘What policy?’” he said. The policies had lapsed eight months earlier, and it was too late to send in the past due amount and get them reinstated.

A Medicare beneficiary must spend three consecutive midnights in the hospital — not counting the day of discharge — as an admitted patient in order to qualify for subsequent nursing-home coverage. If a patient is under observation but not admitted, she will also lose coverage for any medications the hospital provides for pre-existing health problems. Medicare drug plans are not required to reimburse patients for these drug costs.

The over-classification of observation status is an increasingly pervasive problem: the number of seniors entering the hospital for observation increased 69 percent over five years, to 1.6 million in 2011.

The chance of being admitted varies widely depending on the hospital, the inspector general of the Department of Health and Human Services has found. Admitted and observation patients often have similar symptoms and receive similar care. Six of the top 10 reasons for observation — chest pain, digestive disorders, fainting, nutritional disorders, irregular heartbeat and circulatory problems — are also among the 10 most frequent reasons for a short hospital admission.

Medicare officials have urged hospital patients to find out if they’ve been officially admitted. But suppose the answer is no. Then what do you do?

Medicare doesn’t require hospitals to tell patients if they are merely being observed, which is supposed to last no more than 48 hours to help the doctor decide if someone is sick enough to be admitted. (Starting on Jan. 19, however, New York State will require hospitals to provide oral and written notification to patients within 24 hours of putting them on observation status. Penalties range as much as $5,000 per violation. )

The letters arrive almost daily, on official-looking letterhead from a supposed charity, or from the J.M.D. Major Cash Disbursement Office. More blatantly, letters sometimes come from an outfit called Mountains of Money. They announce that the 85-year-old man to whom they’re addressed has won a prize — the amount seems to hover around $11,000 — and explain that to claim it, he has to fill out a form, often complete with a “verification code,” and send it in with a check for $6 or $7.

It’s a scam, of course. As the recipient is told by his worried children, there’s no sweepstakes, no prize. He’s an intelligent and educated man, so “we used to go over the letters methodically, showing how they’re fake,” his daughter-in-law told me. “He acknowledges it. He says yes, he’ll stop. But he keeps going.”

He receives phone calls from scammers, too, and has long conversations with them. So far, the checks he invariably sends have remained small, and he has not done major financial damage. “But the nasty shock could come at any time,” his daughter-in-law said. (I’m withholding names to protect the family’s privacy.)

So the new antifraud hotline started by the Senate Special Committee on Aging will not solve the problem, but it will give harried seniors and family members another place to turn besides local law enforcement, the Federal Trade Commission and adult protective services agencies.

A question for readers: Have you filed an appeal with Medicare after it would not cover nursing home care or prescription drugs following hospitalization — because you were on observation status? We’d like to know about it. Please leave a comment.

“It’s a huge problem,” said Barbi Jo Stim, a geriatric care manager at Jewish Family and Children’s Services of the East Bay, a social service agency in Berkeley, Calif. “If older adults can’t afford the dental work they need, they can’t chew, they don’t get the nutrition they need and that can affect their overall health.”

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Dental assistant Albert Hernandez helped X-ray the teeth of a nursing home resident in San Antonio, Tex.Credit Jennifer Whitney for The New York Times

For some adults with Medicare, the online insurance exchanges created by the Affordable Care Act may offer an alternative (assuming they become functional in the near future). True, the vast majority should not purchase health insurance on the exchanges. But unless they are enrolled in a private Medicare Advantage managed care plan that already includes dental benefits, Medicare beneficiaries are legally permitted to purchase dental plans on the exchanges.

“There is nothing in the Affordable Care Act that prohibits the sale to Medicare beneficiaries of standalone dental plans on the exchanges,” said Leslie Fried, policy and programs director at the National Council on Aging in Washington, D.C.

Still, there are drawbacks. The standalone dental plans for adults can set annual dollar limits on coverage and don’t have to comply with caps on out-of-pocket spending mandated by the A.C.A. for health plans. Insurance premium subsidies and assistance with out-of-pocket expenses are not available. And in some states, exchange dental plans can reject adult applicants because of pre-existing conditions.

The chilling dilemma of “the unbefriended elderly,” who don’t have family or close friends to make medical decisions on their behalf if they can’t speak for themselves, generated a bunch of ideas the last time we discussed it.

One reader, Elizabeth from Los Angeles, commented that as an only child who had no children, she wished she could hire someone to take on this daunting but crucial responsibility.

“I would much rather pay a professional, whom I get to know and who knows me, to make the decisions,” she wrote. “That way it is an objective decision-maker based on the priorities I have discussed with him/her before my incapacitation.”

Elizabeth, it turns out other people have been thinking the same way.

A few years back, Elena Berman, a retired administrator at the University of Arizona, was trying to put her own paperwork in order and wondering about her health care proxy. She’s single and has no children, and her only sibling lives halfway across the country.

“When I tried to think whom I might ask to fill this position, no relative came to mind,” she told me in an interview. Two friends agreed to be her decision-makers, but they are about her own age. “That’s great if I die in five years or so,” said Dr. Berman, who is 66. “But after that, it’s up for grabs.”

With people living longer and families having fewer children, she pointed out, “I see this as a growing population.”

Nancy Wagner, a social worker at Monmouth Medical Center in Long Branch, N.J., encounters this frustration at least once a week: A patient arrives in the emergency room and tells the inquiring staff that yes, she has indeed prepared and signed an advance directive. But, well, she doesn’t have it with her.

On one recent Monday, it happened twice.

First, an 82-year-old woman, feeling numbness in her arm, came in fearing a stroke and underwent a raft of tests. Her son, who accompanied her, was her health care proxy, designated to make decisions for her if she couldn’t make her own — but where was the document saying so? “It’s locked up in the safe deposit box along with my will,” she told Ms. Wagner.

“Luckily, she was alert and oriented and could talk to me,” said Ms. Wagner, who quickly arranged for the woman to fill out a new form naming her son. But what if she’d been unconscious or incoherent?

On the same day, a 67-year-old man came in with pneumonia. He, too, had an advance directive — stored safely at his attorney’s office in New York City. “I’m trying to get in touch with his lawyer,” said Ms. Wagner, who is required to make three attempts to obtain an advance directive if one exists. She was hoping the firm could fax a copy.

A growing number of health care providers are urging older patients to pay for treatment not covered by Medicare or private plans with borrowed money, usually medical credit cards or lines of credit. Read the full story.

Julianne Moore gives a wonderful performance in “Still Alice,” but the film skirts the truth about dementia.Read more…

About

Thanks to the marvels of medical science, our parents are living longer than ever before. Most will spend years dependent on others for the most basic needs. That burden falls to their baby boomer children. The New Old Age blog explored this unprecedented intergenerational challenge. Paula Span will continue to write New Old Age columns twice monthly at nytimes.com/health and the conversation will continue on Twitter (@paula_span) and Facebook.